TWO CASES OF LABIAL CHANCRE IN CIGARMAKERS. BY WILLIAM S. GOTTHEIL, M.D., ATTENDING SURGEON, DISEASES OF THE SKIN, NORTHWESTERN DISPENSARY, NEW YORK. FROM THE MEDICAL NEWS, July 15, 1893. [Reprinted from The Medical News, July 15, 1893.] TWO CASES OF LABIAL CHANCRE IN CIGAR MAKERS. By WILLIAM S. GOTTHEIL. M.D., ATTENDING SURGEON, DISEASES OF THE SKIN, NORTHWESTERN DISPENSARY, NEW YORK. Attention has been called of late in the European journals to the frequency of extra-genital infection with syphilis. It has long been known that such cases occur. Casenave recorded a number in the early decades of the century, and subsequent observers have added to the list. The mass of recorded instances is already too great to be collected. It seems very probable, however, that these unusual infections are even more numer- ous than was ever suspected. An increased familiarity with the early symptoms of the disease, and the inclu- sion of syphilography in the curriculum of our medical schools, have led to a more careful search for the seat of the initial lesion in apparently mysterious cases ; with the result that such unexplained cases are becoming much more rare. No one now believes in the occurrence of syphilis without a chancre, though it may have been unnoticed by the patient. As a chancre has a definite life-duration of its own, though within rather wide limits, one situated within the urethra, within the rec- tum or within the vagina may readily escape the patient’s notice, more especially as it is usually entirely pain- less. On the other hand, a chancre situated upon some portion of the body other than the genitals is liable to be mistaken for a furuncle or boil, or to be neglected entirely. 2 It must never be forgotten that a chancre and the sub- sequent syphilis constitute a venereal disease only by accident. The contagium will grow in any human body that has not already been infected by it. It can enter the body at any point where there is a break in skin or mucous membrane. It can be transferred from one sub- ject to another without direct contact, by means of an object or person acting as intermediary. It is simply because during copulation individuals usually come into close and prolonged personal contact favorable for the transmission of a living, organic contagium that is in the blood, that most chancres are situated upon the genitals. If any other act of social life involved similar processes, chancres would be as common on the organs employed as it now is upon the penis. In certain regions, where peculiar customs prevail, we do indeed find this to be the case. Thus, long series of cases have been recorded in Russia, where the habits of the peasantry are not of the most cleanly or hygienic. A common domestic remedy in that country for certain affections of the eyes, such as furuncles, small abscesses, etc., consists in the sucking or licking the affected part by one of the patient’s relatives or friends. This primitive therapeusis is in vogue with us only in the case of snake-bites, where it has a rational basis and some success. Snake- bites, however, are rare; nor do I know a single case in which the treatment has caused infection of any kind. The common use of instruments that are taken into the mouth has caused many epidemics of syphilis. Notably was this the case among the French glass- blowers,so that governmental interference finally became necessary. The long tube used by a gang of men in common was not to be employed without an “ embout ” or mouthpiece, of which each workman was compelled to have his own ; and heavy penalties were inflicted for a violation of the rule. The men accepted the innova- tion with enthusiasm at first, but they soon relapsed into 3 their former and easier habits ; and Chassagny, the in- ventor of the mouthpiece, records with a sigh the fail- ure of his well-meant efforts. In our own country, with more cleanly habits, such sources of infection are rarer. Yet they do occur, as the two cases that I am about to record will prove. The infective source is of the greater interest, as it directly affects a very large portion of the community—the cigar- smokers. A. McK., aged nineteen, born in the United States, and a cigar-finisher by occupation, came to me at the N. W. Dispensary on January n, 1892. In the first week of December, 1891, she noticed a slight swelling of the upper lip. Soon a small lump appeared, which con- tinued growing in size during the rest of that month and finally became as large as a small walnut. On January istshe first noticed some blotches on the face and body; but these, she affirms, have entirely disap- peared. She gives an indefinite history of a sore-throat early in December. She has grown thin and pale, and has lost strength and appetite. The patient thinks her affection a trivial one, but would like to know why the lump on her lip does not disappear. Though she does not feel very well, she has not let it interfere with her work; she expected it to go away of itself. She claims that her intimate friend, who finishes cigars on the machine next to hers, had the same thing on her lip three months ago, and that it went away in a short time without medicine. She thinks she must have acquired it from her friend, as both drink tea from the same cup at lunch. She has had some little trouble about the genitalia, which she con- sidered of no consequence. The patient is a pale, anemic girl, undersized for her age, and rather stupid. On her upper lip, at about the middle line, is a lump as large as a hazelnut. It is car- tilaginous to the touch, sharply limited, and entirely 4 painless. Its external surface is occupied by an irregu- larly square, excoriated patch, the base of which is uneven, dark greenish-gray in color, and slightly secret- ing. It is a typical initial lesion, and from its location and prominence is noticeable at a considerable distance. A general macular syphiloderm is in full bloom upon her body, though slight upon the face. The character- istic adenopathy is well marked everywhere. She has a diffuse specific pharyngitis. The vagina contains moist papules, and there is a profuse vaginal dis- charge. This, then, is the condition of a patient who claims to 5 be fairly well, and who is merely tired of the disfigure- ment caused by the lump upon her lip. The chief point of interest in the patient’s history, however, is her occupation. Knowing something of the process of cigar-making, I questioned her closely in re- gard to it. That hand-made cigars are liable to be in- fected is a matter of common observation. Anyone who has watched the process cannot fail to have noticed the generally unclean condition of the workman’s hands and table ; but it is the finishing of the cigar that is most obnoxious. Most of the operators that I have seen use their saliva on the tips of their fingers to shape the ends of the cigars. A pot of paste stands on the table beside them, but it is quicker and easier to use the mouth. Besides this one and the same motion will suffice to cut off the redundant corner of the wrapper, and doing this with the teeth saves the trouble of taking up the knife again and cutting the point on the table. I was not aware that the same thing was done with machine-mad& cigars, but the patient was quite frank when I questioned her about it. Machine-made cigars have to be finished in exactly the same way as the hand- made ones. The machine turns out the cigar unpointed, and the finisher completes the product by hand. She bites off the little triangular redundant piece of wrapper, and at the same time wets with her tongue the tip of the cigar, which is then moulded by hand. All the finishers that worked in the same shop as our patient did exactly the same thing. Paste-pots and knives were there, but it took too long to use them. The work was paid for by the piece, and could be done much more quickly in this way. Yes, she had heard something about the practice being forbidden, but no one did otherwise. The patient’s further history was unimportant. She was placed upon the usual treatment, and began to improve rapidly, both as regards the disease and as regards her general health. Both she and her mother, 6 however, absolutely refused to believe in the seriousness and the contagious nature of her malady. She refused to stop work, and continued to make her cigars as be- fore. I saw her some three or four times more, and then she withdrew from observation. I had naturally been anxious to see her friend, from whom she supposes that she caught the disease ; but I found it very difficult to do so. Finally, on February 3d, she came to the dispensary. Her history is as follows : D. D., aged eighteen, born in the United States, in the beginning of October of last year first noticed a sore upon her lip. It began as a little pimple, but soon grew to the size of a nut. The girl gives a full and complete history of syphilis. There was a general macular erup- tion, general adenitis, defluvium capillorum, pharyngitis, etc. The sore on her lip disappeared spontaneously in a few weeks, and the girl did not then, nor does she now, attribute any importance to it or to any of the other symptoms. She works on the machine next to that of A. McK., whose intimate friend she is, and who sleeps with her. After much cross-questioning she admits having gone to a physician once when sick. He gave her a salve and some pills, but did not, she insists, tell her anything about the nature of her disease. The patient is a tall, well-developed girl, of magnificent physique, and apparently in perfect health. A close examination, however, reveals the stains left by a former general macular eruption on the arms and chest. There are two large mucous patches upon the tongue. On the lower lip, a little to the left of the median line, is a small pea-sized, still indurated nodule, evidently the remains of the initial lesion. General adenitis is still perceptible, and there is a typical pharyngitis. This girl worked all through her sickness, and is working still. She invariably finishes the tips of her cigars with saliva. She admits that the finishers have been told not to do so, but she £ays that the practice is 7 universal. She was put upon the ordinary treatment, and improved whilst under observation. She laughed at the idea of having any general disease, and at the danger of contagion. She soon withdrew from observa- tion. Now here were two girls, in the early and most infec- tive stages of syphilis, engaged in the manufacture of an article that is almost invariably taken into the mouth, and using their teeth and saliva to finish the very part of the article that comes in prolonged contact with the delicate and frequently abraded mucous membrane of the mouth. Every single cigar of the thousands that they must have finished in the last four months had carefully deposited upon it saliva that was admixed with the secretion from a chancre. When the sclerosis finally ran its course and disappeared, the secondary mucous patches, of much longer life and just as contagious, took its place. The necessary presence of acrid tobacco-juice in the mouths of these girls supplied exactly the condi- tions favorable for the continuance of the patches. Thus they will probably both continue to have an infective buccal mucosa during the entire active period of their syphilis. Their absolute disbelief in what was told them concerning the nature of their malady, and the certainty that they will not undergo the necessarily prolonged and careful treatment to be cured, render it probable that they will long remain in the contagious stage. Meantime the cigars that they have finished have been scattered far and wide, to be smoked, in nine cases out of ten, without any protection in the shape of a holder between the tip of the cigar and the smoker’s lips. I am well aware that tobacco is supposed to possess cer- tain antiseptic qualities, but they are certainly not very marked, and we do not possess exact data as to their degree. We may hope for the best; but may not these infected cigars explain the origin of some of these mys- terious labial, buccal, and tonsillar chancres that are 8 seen ; and, above all, may they not account for the very numerous cases of syphilis in which the inital lesion is not noticed at all, and the patient, though truthful, entirely fails to give any history of the beginnings of the disease ? The remedy for this particular source of infection is plain. The use of the lips and the saliva in the manu- facture of cigars is a disgusting and filthy makeshift, and should be stringently prohibited. The Hygienic Sec- tion of the New York Academy of Medicine has, I am told, made some attempts in the past to put a stop to the practice, but their efforts have evidently been futile. Both patients affirm that the practice is universal in the large factory in which they work ; and further inquiry has convinced me that the same state of affairs prevails in other factories and in smaller shops. Operatives will never of their own accord make a change that means decreased wages for them. The employers, however, can be reached by law, and they can easily compel their operatives to use the paste-brush and the knife. There are State inspectors for these factories, and the local boards of health cer- tainly have power. Each department and each floor of a factory is under the supervision of a foreman or superintendent, and no practice of the kind can be indulged in without his knowledge. A penalty of suffi- cient magnitude imposed upon the employer for every case of the kind would soon lead him to give stringent orders to his foremen, and without the connivance of these latter the practice could not continue. 25 West Fifty-third Street. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. 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